Tips and Tricks to get the Most out of Your EHR
Contents
1. NoteSwift for Aprima NoteSwift One Boston Place Suite 2600 Boston MA 02108 www noteswift com erento ss d i 2 A wit ANSA ya An 4 4 Vel ies ws hb SE hu ah qt m wor TE he yrs e AR LO ht a 9 s i PC he pg 5 B P i Ter Vase ry mala lie LI Ae gt Mi 7 asa 2 3 d Y 3 ro uv A pae lir D wi 0 at a way nir 1 ilte d mi t a bd D d eid LIT Ln pre T AE tos Me a ATT rye iO osha Pe me u V Woyo Z FW 3 han Lun 97 PANEI N Ai pUAS A A gt tag P kK A M M S MM PELA ad nw est TES 1 K 3 Neer mes rt y est a Ne UM S A gt dis M aa E CUIU s SUR Wo ERE je Bt Ne Heh AG 3 SM 4 em 5 d RAV Ui r9 ie AN toy aye f tuU EC lan wat Pr pa AA ptg nal rene nh ab o ul FONE a a D n hey te wer LP wee p 7 OID 5 Ma dL OMIM SC w T T 8 mx i e e lt a rt ee Se n 1 ro MUS Met Sear PAd a ar MAS uA A Sk MM TCI VES Rens t A oi ag ir i NM NEM e ante WEIL at alas PN Wa O PN a I Oe e Murs Ny d ARR AQ deu y S v 4j as E ERA 4 Aes AE A ap iate d NY aot LN T Ta 4 7 5 4 vr LL TR ee ENS ANS edly e Ne Ae A D Copyright Note Swift Co2. EE EDA QE lt New vitais cc Hpi mx Resuts ros Pe rx se so Pian aesessmenFoms Comdem crr ar Notes 81 0 3 51 uo py aop xa B swio4 uoneonpg fF uoneuuoju ust GE dn ojo Gea 12 In order for NoteSwift to interact properly with Aprima you should always have DMPE Aprima and NoteSwift running at all times NoteSwift commands expect that the note window shown above is in view Now we are ready to get started Note Swift NoteSwift Forms NoteSwift forms allow you to dictate free text narrative and structured data where NoteSwift does the searching for you from a defined list In this document we go through each NoteSwift form and show you how NoteSwift s SwiftNav technology helps you create the patient note quickly and easily whether you need free text or structured data NoteSwift Forms are Chief Complaint History of Present Illness Review of Systems Past Medical History Social History Surgical History Family History Allergies Current Medications Physical Exam Diagnosis Prescribe Plan Services Ordered Services Provided The Plan tab is reached by speaking one of the following commands Internal Notes Visit Notes Patient Instructions Plan Exercise Heturn Visit Note Swift Chief Complaint Call up the Chief Complaint form Say Chief Complaint The NoteSwift Chief Complaint form appears
3. 99204 OFFICE VISIT NEW LEVEL 4 Complete 3 items I have reviewed the Surgical History with patient Then click or say Next if you wish to dictate more history or Done if you are finished dictating the history Note Swift Medication History Call up the Medication History form Say Med History Dictate the medications your patient is taking Try this example to see how to dictate medications in this form Say mg as milligrams Say Lisinopril 20 mg daily Fille View E 5 ER Rha 506 e m x BH OMAR Ei GU x E ZR WE A Nen Vitals 16 HP Results ROS PE o Rx se SO _ Plan _ Assessment Forms Confidential CPP Rx Summary Find Medication History File lisinopril 20 mg tablet lisinopril 20 mg hydrochlorothiazide 12 5 mq tablet lisinopril 20 mg hydrochlorothiazide 25 mq tablet uo F121 H OY n s Medication History aon pe B swio4 uoneonp3 S uonewsoyujysi GY dn wojo ez Drug lisinopril 20 mg Alternative V Include brand name V Include generic name Include user defined medications Include inactive medications Alias eT Cee H Search completed in 2840ms EH Incomplete visit Pertinent 1 item I have not reviewed the Medication History with patient You will see the Aprima Find Medication History window where you will click the appropriate me
4. Recommended Restricted To Patient Patient Instructions Instructions Return Visit Return Visit Visit Notes Visit Notes Note Swift Note Tab Note Tab Note Tab Note Tab History Of HPI History History of Next Category Present Illness Present Illness Review Of Systems ROS Select All Systems Clear All Systems Next Symptom Social History Social History Select All History Clear All History Services Orders Services Ordered Ordered Services Services Provided Performed Services Performed Service Performed Note Swift
5. mx resus ros pe ox Re sp so Pian __ Assessment Forms Confidential crr __ v Notes _ Description normal excursion no pain H auscultation Diffuse inspiratory wheezes H respiratory effort rhythm Overall no retractions normal rate uoneurioju ust Be Norvasc oral 5 mg Problem Diagnosis History s s System auscultation Finding Diffuse Description inspiratory wheezes Note Wheezing noted bilaterally other nodes axilla arm nodes inquinal nodes SS SI S 3 ISI ISI 7 Incomplete visit Detailed 5 Systems 12 Bullets charted a Default Batch 3 31 2014 noteswift 2 Now let s get back to our original exam Note Swift suo uonponp3 i Diagnosis To add a diagnosis to the patient s chart call up the Diagnosis form Diagnosis Say your diagnosis in this example Labyrinthitis NoteSwift will search for the diagnosis You can then dictate an assessment narrative associated with that diagnosis Rx Summary Tem SNOMED BILLSPEC RAF 4 Allergies Labyrinthitis circumscribed bilateral 61794006 BS 0 0000 3 Allergen Reaction Labyrinthitis circumscribed left 61794006 BS 0 0000 Food Allergy Labyrinthitis circumscribed right 61794006 BS 0 0000 Shellfish rash hives Labyrinthitis serous bilateral 416740001 BS 0 0000 Envt Allergy Labyrinthitis serous left 41674001 BS 0 0000 Latex La
6. Dictate first the system followed by the patient s complaint For example say Neurologic Dizziness ea Remember that the comma means to pause after the first word which tells NoteSwift to auto AN jump to the next form field V S S The word dizziness will appear in the Chief Complaint form M 3 25 2014 Smith Ede View 5 9 6 7 RE 22 e 6 lt RONG K 4 2 5 en B 8 vials cc hei ux Resuts Ros re ox m se so Pen Assessment Forms Confidential cpp 4 b RxSumman Notes 5 uon E swowyeny ajo B suo uoneonp3 uoneuuoju ws de es n s Chief Complaint Wm J mesmese Note Swift Now dictate a Note for the Chief Complaint form such as For 6 Weeks The Note form is updated with this information If finished click or say Done If you would like to dictate additional information say Next and dictate another complaint following the steps as noted above You can always move between the fields in the NoteSwift form by saying System Symptom Note Note Swift History of Present Illness Call up the History of Present IlIness form HPI The History of Present Illness form appears To record the patient s history you will specify the Symptom Category and Description with optional notes based on the list of symptoms captured during the Chi
7. Confidential CPP 4 v Notes 3 B pl LT T info Del lt H83 03 386 32 Labyrinthitis 4 Patient has symptoms E 7 3 circumscribed bilateral m 0 E uonewoju s1 is suo uonponp3 f 250 00 DIABETES TYPE II 719 46 JOINT PAIN L LEG 789 00 ABDOMINAL PAIN 780 4 DIZZINESS AND GIDDINESS 724 2 466 0 ACUTE BRONCHITIS 250 01 DM W O COMPLICATION TYPE 780 79 462 ACUTE PHARYNGITIS 788 1 DYSURIA 787 01 465 9 ACUTE URI 782 3 EDEMA 4 477 9 ALLERGIC RHINITIS 530 81 ESOPHAGEAL REFLUX 733 00 691 8 ATOPIC DERMATITIS 401 9 ESSENTIAL HYPERTENSION 724 5 BACKACHE 780 60 FEVER NOS 785 1 F 401 1 BENIGN HYPERTENSION 300 02 GENERALIZED ANXIETY DISEASE 486 P 490 BRONCHITIS 784 0 HEADACHE 1 727 3 BURSITIS 389 9 HEARING LOSS 786 50 CHEST PAIN 455 6 HEMORRHOIDS 780 71 CHRONIC FATIGUE SYNDROME 272 4 HYPERLIPIDEMIA 338 29 CHRONIC PAIN 244 9 HYPOTHYROIDISM 473 9 CHRONIC SINUSITIS V04 81 INFLUENZA VACCINE 290 13 DEPRESSION 564 1 IRRITABLE COLON Default Batch 3 31 2014 noteswift Click or say Done when you are finished with Diagnosis Note Swift Prescribe To prescribe a medication in a patient note call up the Prescribe form Prescribe Now dictate your prescription medication For example Meclizine 25 mg QID quantity 100 NoteSwift enters the medication name and correct dosage and frequency A
8. Include Monograph ped ay oueuiny E xone Busog EP 1 18 15 es for back pair for headache 3 for heartbum Quantity 30 for pain Start Date 43 31 2014 Estimated End Date 4 Category suo uonponp3 i Tablet Pharmacy Inst _g SAVINGS FOR UNINSURED PATIENTS ngs Prescribe Internal Note 4 i US Authorization Prescriber Patterson Frank Pharmacy Formulary Status Not Available Defaut SIG OK Cancel Drug screening has completed Default Batch 3 31 2014 noteswift T Incomplete visit Default Batch 3 31 2014 noteswift 7 Click the OK button on the Aprima prescribe window to submit the prescription You may prescribe additional medications at this point or Click or say Done when you are finished with Prescribe It is important to make sure that you selected the desired medication and the prescription window shown above is displayed before you say Next or Done to have the prescription fields properly transferred to the note Click the OK button on the prescription window before proceeding with NoteSwift Note Swift Orders To order lab work imaging or other tests using NoteSwift call up the Services Ordered form Say Orders Now specify the orders Say CBC Find Service Order CBC WITHOUT PLATELET CBC DIFFWBC W O PLATELET HCPCS COMPLETE CBC W AUTO DIFF WBC CPT CBCidiffWBC w o platelet HCP
9. OD vius cc um x resus Ros Pe ox Re se so Pen _ Assessment Forms Confidential CPP Notes es Desc Neurologic H cranial nerves Shellfish rash hives C CN3 4 6 Envt Allergy extraocular movements Left nystagmus on left gaze 3 aut intact am icons aspirin oral 81 mg lisinopril oral 20 mg Norvasc oral 5 mg Problem Diagnosis History E uonpunoJu isiy s swo uoyeonpy d wm System Integument System cranial nerves Finding 3 Description Left nystagmus on left gaze Note deep tendon reflexes sensation mental status gait coordination motor speech Psychiatric behavior psychomotor act mood and affect appearance attention speech 13 EEG 0p A ES E Ea Incomplete visit Problem Focused 0 System 1 Bullet charted 8 Default Batch 3 31 2014 noteswift 5 Note Swift Exam by Exception Aprima supports the ability to enter exams by exception Let s diverge from our current exam for a moment Say this patient came in with coughing and wheezing and we are going to do a Respiratory exam For this example the Respiratory Exam PE Type is selected Then say Select All Systems This will select pre defined defaults for all systems in the current exam E 3 31 File View amp E 4 2 mA 5 Nw 8 2 4 Eh K em lt KB vitals cc um m Re
10. 20 mg Norvasc oral 5 mg swo uoneonp3 fF uoneuuoju ust Be Problem Diagnosis History Name Onset ngs Plan Incomplete visit Default Batch 3 31 2014 noteswift F Note Swift Internal Notes Visit Notes and Patient Instructions all use free form dictation and do not require any additional steps Click or say Done when you are finished with Plan notes Note Swift Appendix 1 NoteSwift Command Cheat Sheet This is the list of commands available to call up NoteSwift forms and the commands available within each form In all forms in addition to Done Next and Cancel you can dictate the name of any field within the NoteSwift form to move the cursor to it Note Tab NoteSwift Form Commands Form Specific Commands Allergies Allergies or Allergies Food Drug Environmental Select All followed by History Clear All History Medications Medication History Med Select All History Clear All History Item History Medications Past Medical Past Medical Past Select All History Clear All History History Medical History Medical L X History Past Surgical Past Surgical History Select All History Clear All History History Past Surgical Surgical History Family History Family History Select All History Clear All History Next Relation Next Disease Dead esr Select All Systems Clear All Systems Check Plan Exercise Plan Exercise within the note text
11. CS Complete CBC automated HGB HC HCPCS Blood count complete CBC automate CPT Albumin serum plasma or whole blood CPT Complete CBC automated HGB HCT RBC WBC without platelet count Complete CBC automated HGB HCT RBC WBC without platelet count an WBC differential count LABCORP Blood count complete CBC automated Hgb Hct RBC WBC a count and automated differential WBC count HCPCS G0306 Short text CBC diff WBC w o platelet Long text Complete CBC automated HGB HCT RBC WBC without platelet automated WEC differential count HCPCS G0307 Short text CBC without platelet Long text Complete CBC automated HGB HCT RBC WBC without platel CPT 85027 Short text Complete CBC automated Medium text Blood count complete automated Envt Allergy Active Medications aspirin oral 31 mg lisinopril oral 20 mg Norvasc oral 5 mg Problem Diagnosis History Name Onset CPT Copyright 2011 American Medical Association All Rights Reserved The Addin took 8002ms Incomplete visit CPT Copyright 2011 American Medical Association All Rights Reserved Default Batch 3 31 2014 noteswift You will see a search window with all of the options available You can 1 Say or click Next or Done to accept the first item in the list 2 Dictate the code or description of the desired item Saying Name will place the NoteSwift cursor back in the n
12. File View ORE a o 0 emj HANG bT E dU E 2 Em ED RA 8 Ne vitals cc HPI Hx Results ROS PE ox R sp SO __ Plan __ Assessment Forms Confidential CPP Feci Allergies Allergen Reaction 1 Quim Anwer ssi Deas 20 pack year history 1 uopi FE swowyeny II al l Question tobacco history Answer curent every day smoker aon pe Rl suuo uoneonpg m uoneuuoju uet MS dn moyo4 Ga o O O a oa Has the patient ever used illegal drugs Number of vears abusina druas Pertinent 1 item I have reviewed the Social History with patient Press the Next hotkey The text appears in the Aprima window and you can continue dictating more social history information Once done with your dictation Click or Say Done The Good Doctor Says Don t smoke as it is bad for your health Note Swift Surgical History Call up the Surgical History form Say Surgical History The NoteSwift Surgical History form appears Say Appendectomy d amp MEA 2 0 2 85 2 8 lt Nee 8 Cn fide d Ei 6 57 2 H a vis cc Me Hx resus Ros re ox rx se so Pn Assessment Forms Confidential cPP_ _4 F Notes 8 wing E Status Spey 0000 Inactive 80061 LIPID PANEL 99213 99213 EST PATIENT LEVEL III 82565 CREATININE 84479 ASSAY OF THYROID T3 OR T4
13. alization second trimester delivered current hospitalization third trimester Hypertension due to catecholamine excess Hypertension due to hormonal excess Ll mmartannian din ta harmanal mme You may click to select or dictate the specific code ICD10 and or ICD9 depending upon the Aprima configuration at your site Let s try an example with an ICD9 code Say Problem 401 9 Note Swift You should see the single item corresponding to that code as follows File View 57 2 aO em E 0 A MEA EDA AE cc HPI Find Diagnosis Code 10 ON ngs Past Medical History m Search completed in Oms Then click or say Next if you wish to dictate more history or Done if you are finished dictating the history A word about dictating ICD10 codes ICD10 codes can be complex However you can dictate them accurately if you wish using a combination of 1 Military alphabet Alpha Bravo Charlie etc 2 Capitalization commands 3 Spacing commands You can try to dictate an ICD10 code for the previous problem Instead of 401 9 in the previous example say Capital I no space 10 Note Swift Social History Call up the Social History form say Social History The Social History form appears Say Tobacco History Current Every Day Smoker 20 Pack Year History Orr mne 1
14. ame field 3 Click on the desired item Press the Next hotkey to enter the diagnosis into the chart Note Swift 6 15 Be su o 4 uongonp3 f Say MRI You will see the Aprima Find Service order window again To call up a specific procedure for example MRI Brain with and without contrast Say Name 70559 And the search will be narrowed down to the specific test B lt E gS E E 3 m E 8 3 TT S a Note Swift Plan To call up the Plan form you can say any of the following Internal Notes Visit Notes Patient Instructions Plan Exercise Return Visit Dictate each item s information In the case of Plan Exercise you can dictate recommended or restricted and then continue to dictate the exercise note NoteSwift will automatically choose the proper radio button either Restricted or Recommended In the case of Return Visit you can dictate the length of the visit and NoteSwift will automatically choose from the Days Weeks Months and Years radio buttons E 3 31 2014 Smii File View 2 0 E 95 2 B lt 0 4 E em 5 ES BB 318 a e D a Return Vist 2 ODays Weeks Months Years z _ a Exercise Recommended Restricted To Food Allergy Shellfish rash hives Envt Allergy Latex uo F101 Active Medications aspirin oral 81 mg lisinopril oral
15. ant to run or save noteswiftforaprima msi 5 21 MB from download noteswift com Cancel 2 NoteSwift requires the Microsoft Net Framework to run If it is not already installed on your system a dialog will appear prior to installing it Accept the Microsoft Supplemental License Terms by clicking on the Accept button in the dialog Note Swift TL NoteSwift Setup For the following components NET Framework 3 5 SP1 Client Profile Please read the following license agreement Press the page down key to see the rest of the agreement MICROSOFT SOFTWARE SUPPLEMENTAL LICENSE TERMS MICROSOFT NET FRAMEWORK 3 5 CLIENT FOR MICROSOFT WINDOWS OPERATING SYSTEM Microsoft Corporation or based on where you live one of its View EULA for printing Do you accept the terms of the pending License Agreement If you choose Dont Accept install will close To install you must accept this agreement 3 After the NET installation completes you ll see the NoteSwift welcome screen Select Next Welcome to the NoteSwift for Aprima Setup Wizard The Setup Wizard will allow you to change the way NoteSwift for Aprima features are installed on your computer or even to remove NoteSwift for Aprima from your computer Click Mext to continue or Cancel to exit the Setup Wizard 4 Review and accept the terms of the NoteSwift End User License agreement Select Next Note Swift Please read the following li
16. aon B suuouoneonp3 fF uoneuuojupws fe dn moyo4y Ga Note Swift Review of Symptoms Call up the ROS form ROS Dictate the system and corresponding symptoms into the ROS form indicating whether it is positive or negative NoteSwift initially defaults to positive findings if you would like to dictate a negative simply say negative to toggle the state In the example below the patient is positive for dizziness and tinnitus File View E BENE HE m ROD em Bons MGs A G4 bringen TE Nee vs cc Resuts 808 PE Dx 1 sp so Pin __ Assessment Forms Confidential CPP Notes 89 Neurologic Has dizziness 0 H sua yey DELLI al Symptom 8 fa 7 J ing loss fy J O loss P memory O hi FTN TN 8 seizure OO i 2 7 EN B J difficulties aopa B suuo4uoneonp3 S uoneuuoju ust BI an mopo es i A i gt syncope O i ji O 0 I amp wc 1 a 2 4 1 YG Say Neurologic Dizziness To add the next symptom for dizziness say Next Symptom Tinnitus In Left Ear Note Swift Once your review of symptoms is complete say Done Or click the Done button The Good Doctor Recommends If you have symptoms listed in more than one system pressing or saying Next will b
17. ard Launch NoteSwift for Aprima Cancel 8 If this is your first time installing you ll have to enter the activation key given to you at time of purchase in order to register the software Note Swift must first be activated with a valid license key You received this key when you purchased NoteSwitt Enter your license key below and click Activate to continue 9 You may also be required to enter registration data following entry of the License key if this is a first time activation for the key Once these steps have been completed NoteSwift will launch Note Swift Creating a NoteSwift Profile 10 Now you must create a user for NoteSwift Click the Add button and you ll see the following dialog displayed 11 Enter a user name select the EHR which is Aprima and select the Version of Aprima you are running then click Done When the dialog is dismissed click the Open button to open your newly created user profile Note Swift We are now ready to start working with NoteSwift Note Swift Aprima Interface The default setting for Aprima is to have all of the panes expanded This is the state NoteSwift expects Aprima to be in so that it can interact with the EHR If you are experiencing any problems with recognition you may want to check that all your panes in Aprima are expanded and not closed File View 7 22 SE ROD em BRON K A
18. ay have additional consumer rights under your local laws which this license cannot change To the extent permitted under your local laws the contributors exclude the implied warranties of merchantability fitness for a particular purpose and non infringement VcCom API Copyright 2014 Alan MacAree All Rights Reserved Note Swift Contents COD A NN OR iii ThIBSSSEIESE oce atiss E iussu epe iE dM EnIgE M ubi MESE opc D MUPSDU MP LSU UPS a DEAD DUM DERE DEA UE 2 Bas HONS aa cvnnnuch cura syste vines tarry thaerrateeseovior ate o tien tanhas ortega eee 2 About This Document Typographic Weirdness and Helpful Info sees 3 Download VG BIA rz d NOM eea mm 6 DOWO IE essei pedir ISI IsF ap NEP DII E DIEM IUNII EU MM MU 6 Cre3uns a NOtESWIFEPIODIGC iode si teles ausi tui ede cote ce clem PL MuF Le E Detu bUDESI EOM IER UD 12 WIRE FC m IT ETE RR 14 Meise s T RM eld RT evenness T T EU 15 eludere O T eeone E T 16 History of Present 5 E 18 PROVIEW ol VP O ea pr ime De oberen i Miberwa a dns A 21 B Tal O N RT RT 23 SOCANT oa NEN RR Emm 25 STG TES OY Lo coder cere cian cee E E MEME MEE MEM PUMP MM 26 Medicar om PIS UO e RR RR em 27 FE ANTAL Ami iioi mm 29 ee r ee eee 31 SUE een epniresees oes Ray 32 Exam DV EXORDIO kee
19. byrinthitis serous right 41674001 BS 0 0000 Active Medications Include Non Billable aspirin oral 81 mg Include Non Specific lisinopril oral 20 mg _ Include Synonyms Norvasc oral 5 mg C Return Distinct Snomed Codes Maximum items returned 1 for no limit 500 Problem Diagnosis History Name Onset uonguijoju isiy isl suo uoneonp3 fF IcD9 Z Diagnosis Item labyrinthitis Note Patient has systems consistent with labyrinthitis and has had no improvement for the last 6 weeks He 786 50 CHEST PAIN 455 6 HEMORRHOIDS 780 71 CHRONIC FATIGUE SYNDROME 272 4 HYPERLIPIDEMIA 338 23 CHRONIC PAIN 244 9 HYPOTHYROIDISM 473 9 CHRONIC SINUSITIS V04 81 INFLUENZA VACCINE 290 13 DEPRESSION 564 1 IRRITABLE COLON Incomplete visit Default Batch 3 31 2014 noteswift 2 If the Diagnosis search returns more than one item you can either 1 Sayorclick Next or Done to select the first diagnosis in the list default 2 Click on the specific diagnosis desired 3 Dictate the desired diagnosis either by name or ICD 9 or ICD 10 code After you have selected the diagnosis say Note to add any narrative text into the note field Note Swift Press the Next hotkey to enter the diagnosis into the chart M 3 File View i A ME 2 2 AM A Ae BOB was emj EKBER H o CD vials cc wer He Resus Ros re ox m se so Pian _ Assessment Forms
20. cense agreement carefully NoteSwift Inc END USER LICENSE AGREEMENT Your acceptance of the terms of this End User License Agreement Agreement is required before your use of the accompanying software This Agreement is between you Licensee or you and NoteSwift Inc and or one or I accept the terms in the License Agreement I do not accept the terms in the License Agreement me CEE Cae 5 You ll be asked to specify the installation directory It s recommended that you stay with the default location provided Select Next Note Swift This is the folder where MoteSwift for Aprima will be installed To install in this folder dick Next To install to a different folder enter it below or cick Browse Folder Note Swift 6 The NoteSwift installer will then ask you to click Install to install the software The Setup Wizard is ready to begin the NoteSwift for Aprima installation Click Install to begin the installation If you want to review or change any of your installation settings dick Back Click Cancel to exit the wizard 7 Theinstaller will show a progress dialog while the product is being installed and then you ll see the final dialog showing the completion of the install Select Finish Note Swift jl NoteSwift for Aprima Setup Completing the NoteSwift for Aprima Setup Wizard Click the Finish button to exit the Setup Wiz
21. d distribute its contribution or any derivative works that you create Note Swift Copyright B Patent Grant Subject to the terms of this license including the license conditions and limitations in section 3 each contributor grants you a non exclusive worldwide royalty free license under its licensed patents to make have made use sell offer for sale import and or otherwise dispose of its contribution in the software or derivative works of the contribution in the software 3 Conditions and Limitations A No Trademark License This license does not grant you rights to use any contributors name logo or trademarks B If you bring a patent claim against any contributor over patents that you claim are infringed by the software your patent license from such contributor to the software ends automatically C If you distribute any portion of the software you must retain all copyright patent trademark and attribution notices that are present in the software D If you distribute any portion of the software in source code form you may do so only under this license by including a complete copy of this license with your distribution If you distribute any portion of the software in compiled or object code form you may only do so under a license that complies with this license E The software is licensed as is You bear the risk of using it The contributors give no express warranties guarantees or conditions You m
22. dication from the list or say press Next to select the first in the list Note that you may also get a dialog asking if you d like to specify the SIG details which you can choose to do or dismiss the dialog Practice entering medications this way with the following medications Aspirin 81 mg daily Norvasc 5 mg daily Note Swift t 57 bs E3 TB a B SALT x 8 22 4 mG ER 2 ae lt New vials cc ue ux Resus Ros pe ox m s0 Pian 7 Notes a y dn ojo es sluawyseyy Filter _ Active Meds um Medication Name Doctor Stop D C Refil Chg Del Prnt Info niin H ACE Inhibitors 3 lisinopril 20 mg tablet Unknown none ma _ Patient takes no medications Calcium Channel Blockers Dihydropyridines Patient has been seen by ancther Norvasc 5 mg tablet Unknown none D C Refil ma PEN E Salicylate Analgesics aspirin 81 mg Unknown none DIC Ren x capsule delayed release wnmog E uonewojuj ISA A nfs Medication History apo Surio uoneonpy fF If you have more detailed dosing information you wish to enter you click Yes when you are asked to specify SIG details and once the window appears Click or say Next or Done NoteSwift will fill in the values for you You can learn more about this in the Prescribe form section of this manual Note Swift Family History Call up th
23. e Family History form Family History Dictate into the family history form pausing where you see commas and remembering to say or click Next after you have finished dictating each individual s history Mother Hypertension Alive Father Diabetes Mellitus Type 2 Deceased Died at age 62 E 3 25 2014 Sm File View 9 6 7 2 2 99 6 eim x 8 0 wes 4 OOS 5 EDA DE lt Ne 0 vis cc rel Hx Reus Ros pe ox rx se s0 Pian _ Assessment Forms Confidential CPP a gt Notes Entry mode Relationship Disease uoi Fl squeunpeny gt Mother ngs Family History Complete 3 items I have reviewed the Family History with patient Note Swift because there may be more than one daughter for example each with more than one disease To enter the next disease for the current relation say Next Disease Then enter the next disease for that relation If you are on a relation such as daughter and you say Next and then say Daughter you ll be entering disease information for a new daughter relation The only two exceptions to this case are Father and Mother Any entries for these relations will be appended to the same father or mother record Click or say Done when you are finished with the family history Note Swift Allergies Call up the Allergies form Say Allergies Then speak the name of the allergy category Food Drug En
24. e Next and Done functions When we say press the Next hotkey in an instruction this means whatever hotkey you have defined to work best for you Note Swift The Good Doctor icon Whenever you see this icon it means we have some important and helpful information for you from the Good Doctor and founder of NoteSwift Dr Chris Russell These tips and tricks will help you learn best practices when working with NoteSwift and your EHR Note Swift Download and Installation Downloading In order to download NoteSwift on your computer please take the following steps 1 Install NoteSwift for Aprima on your computer by entering http download noteswift com aprima client noteswiftforaprima msi into your internet browser and hitting the enter key You will get a dialog asking you whether you d like to run or save noteswiftforaprima msi Select run O ABOUT US PRODUCTS TESTIMONIALS SUPPORT amp TRAINING CONTACT US 6 DRAGON NoteSwift is available for m many EHR applications uH v amazing charts e Developer Program EN Allscripts Approved Application Bridge the gap between Dragon Medical and your EHR NoteSwift is the bridge between Dragon Medical Practice Edition and your EHR NoteSwift tightly integrates with your EHR to give you the speed and accuracy you need when creating patient documentation Maximize time with patients and minimize time documenting Save time and money Go home Do you w
25. e Software THE SOFTWARE IS PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND EXPRESS OR IMPLIED INCLUDING BUT NOT LIMITED TO THE WARRANTIES OF MERCHANTABILITY FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT IN NO EVENT SHALL THE AUTHORS OR COPYRIGHT HOLDERS BE LIABLE FOR ANY CLAIM DAMAGES OR OTHER LIABILITY WHETHER IN AN ACTION OF CONTRACT TORT OR OTHERWISE ARISING FROM OUT OF OR IN CONNECTION WITH THE SOFTWARE OR THE USE OR OTHER DEALINGS IN THE SOFTWARE Cryptolicensing for Net Copyright 2007 2014 LogicNP Software Microsoft Public License Ms PL This license governs use of the accompanying software If you use the software you accept this license If you do not accept the license do not use the software 1 Definitions The terms reproduce reproduction derivative works and distribution have the same meaning here as under U S copyright law A contribution is the original software or any additions or changes to the software A contributor is any person that distributes its contribution under this license Licensed patents are a contributor s patent claims that read directly on its contribution 2 Grant of Rights A Copyright Grant Subject to the terms of this license including the license conditions and limitations in section 3 each contributor grants you a non exclusive worldwide royalty free copyright license to reproduce its contribution prepare derivative works of its contribution an
26. ef Complaint section For example Dizziness Quality Vertigo File View am 2599 6 eim BAN R Ki MER EDA QE New 4 5 27 oo sachsen The data will appear in the structure note window If you wish to enter another category for the current symptom say Next Category Let s add more data for dizziness Say Exacerbating Factors Position Change patient still gets dizzy if he turns his head to the left or the right Note Swift File View 9 5 ting 2 99 6 eim x 8 0 8 us 2 MEA EDA Ged vitals cc uer ix Resuts Ros ec ox m se so Ph Assessment Forms Confidential CPP 4 v Notes uong E siawgyoey 1 suo uoneonpg F uoneuuojupwstA My dn mojoy e Symptom dizziness Category exacerbating factors Note Patient still gets dizzy if he tums his head to the left or the right To add to the information You can then say or press Next to enter the next Symptom Category Description Note group or use your hotkey to click the Done button or say Done Note Swift E 3 25 2014 Smit File View 9 BERE 22 a 1 99 6 eim lt gt Bamm Ki 4 ME EDA QE lt Nec E Patient still gets 0122 if he turns his head to the left or
27. istory of Present Illness e Where you need to pause your voice for a moment in between commands we put a comma in the instruction For example Exam neuro numbness on the right foot You would pause briefly where the commas appear This is where NoteSwift knows to auto jump to the next field e If the NoteSwift form has a Next button it allows more than one listed item Say or click Next to add each item into your form When finished say or click Done to enter all information into the form Note Swift e lf you are using a PowerMic hand held microphone you have the ability to define hotkeys that can enter text and navigate you around the screen The PowerMic uses the defaults below You can find more information on how to set your hotkeys in your PowerMic and DMPE documentation Global and Dictation Box default Press Shift Tab y Fast Forward Global and Dictation Box default Press Tab g Stop Play Global and Dictation Box default Accept default settings 3 Custom Left Global default Force command recognition Dictation Box default Press Cancel Enter Select This is the predefined hotkey to Global default enter text for the PowerMic II Transfer text Dictation Box default Hidden Dictation Box on off NOTE In this manual we assume you will dictate Next and Done or that you will use a predefined hotkey on a microphone or your keyboard to accomplish th
28. list will appear in Aprima showing the medication found Click on the correct medication in the list and choose OK on the Aprima window A dialog may appear with drug interaction information etc asking for acknowledgement and if you want to continue Choose Yes E 3 31 2014 Smi File View amp 8 lt 8 2 95 2 1 2 2 6 7 F CO 181210 El meclizine 25 mq chewable tablet meclizine 25 mq tablet uous 6 Shellfish rash hives Envt Allergy Latex Active Medications aspirin oral 81 mg lisinopril oral 20 mg Norvasc oral 5 mg suo uonponp3 i Problem Diagnosis Drug Z meclizine 25 mg Alternative Include brand name Include user defined medications n s Prescribe meclizine 25 mg 4 times a day quantity 30 refills none Name meclizine n Search completed in 1529ms n none known none Incomplete visit Default Batch 3 31 2014 noteswift E Note Swift The Aprima prescription window will appear Click or say Next and NoteSwift will populate the prescription fields for you SIG Writer Smith John 445 M 30 Year Standard Custom Administered Sample Given PH E Sliders Change strength _ meciizine 25 mg tablet 3 Click below to edit the Directions 1 Tablets PO QD gj DAW Maintenance Medication C
29. ne eee merc non E ee rr ere enna Core mid et eee eee 32 Pec ltem M eae 35 PSS UNS MR T T 37 S qoc 39 HC MEN Um 41 Appendix 1 NoteSwift Command Cheat Sheet 251222115 nennen enne nennen nnne nnns 43 Note Swift Introduction First Things First Please check the following before starting 1 Do you have Dragon Medical Practice Edition DMPE installed 2 Do you have Aprima installed 3 Do you have NoteSwift installed The section entitled Download and Installation gives instructions on installing NoteSwift for Aprima If you can answer yes to all three then continue If you need to install any of the programs listed above do so before proceeding Note Swift Assumptions This document assumes that you are comfortable using speech recognition and that you are able to work with your EHR capably with or without speech recognition If you are not comfortable with either seek training before using NoteSwift Note Swift About This Document Typographic Weirdness and Helpful Info There are certain typographic conventions in this document which once you learn them will help you discern what is typed clicked or said in each example and exercise e NoteSwift commands words you say to NoteSwift when you want something to happen are in bold and initial capitals such as H
30. pyright Copyright Note Swift More time with the patient Less time on the chart 2010 2014 NoteSwift Inc All Rights Reserved NoteSwift the NoteSwift logo SwiftNav and auto jump are registered trademarks or trademarks of NoteSwift Inc in the United States or other countries All other names and trademarks referenced herein are trademarks of NoteSwift Inc or their respective owners Designations used by third party manufacturers and sellers to distinguish their products may be claimed as trademarks by those third parties Dragon Medical Practice Edition and Powermic are registered trademarks or trademarks of Nuance Communications Aprima and the Aprima logo are either registered trademarks or trademarks of Aprima Medical Software Inc in the United States and or other countries The MIT License Copyright c 2007 James Newton King Permission is hereby granted free of charge to any person obtaining a copy of this software and associated documentation files the Software to deal in the Software without restriction including without limitation the rights to use copy modify merge publish distribute sublicense and or sell copies of the Software and to permit persons to whom the Software is furnished to do so subject to the following conditions Note Swift Copyright The above copyright notice and this permission notice shall be included in all copies or substantial portions of th
31. ring you to a clear form where you can dictate symptoms within a new system A note about how NoteSwift searches for items In many cases it is possible to dictate only the beginning of an item or a word contained within This can be very convenient when dictating a difficult item such as CN3 4 6 as you will see in the Exam form example NoteSwift searches first for an exact match and if it does not find one it will look for an item in which your dictated text is contained If there is only one match it will be selected If there are multiple items containing the text NoteSwift will select the first one it encounters Note Swift Past Medical History Bring up the Past Medical History form Say Past Medical The Past Medical History form appears To enter the medical history of the patient Say Hypertension A list appears If more than one choice appears there are several ways to choose the item you wish to select Hypertension associated with diabetes Hypertension associated with diabetes Hypertension associated with diabetes Hypertension associated with diabetes Hypertension associated with transplantation Hypertension associated with transplantation Hypertension associated with transplantation Hypertension associated with transplantation i icati childbirth and childbirth and ium childbirth or ium first trimester childbirth or the ium delivered current hospitalization delivered current hospit
32. us ROS re m m se so Pe _ Assessment Forms Confidential CPP __ 4 Rx Summary Notes uoneig E other nodes axilla arm nodes inguinal nodes auscultation Incomplete visit S sS S s S S K S S general appearance Findings well nourished 1 well developed H Ears Nose Throat H external ear Overall normal appearance Zl Eindims 4 Expanded Problem Focused 5 Systems 11 Bullets charted 16 5 8 Allergies Allergen Reaction Food Allergy Shellfish rash hives Envt Allergy Latex Active Medications aspirin oral 81 mg lisinopril oral 20 mg Norvasc oral 5 mg Problem Diagnosis B Default Batch 3 21 2014 noteswift uonpurioju sia Be suijo4 uongonp3 f NoteSwift will select all the pre defined defaults for this exam type and insert them automatically into the note In this example we want to replace the default setting for auscultation to indicate wheezing Say Auscultation Check Note Swift Notice that the Check command toggles the state of the checkbox next to auscultation removing the pre defined default from the note The NoteSwift cursor will be positioned on Finding Say Diffuse inspiratory wheezes Wheezing noted bilaterally Click or say Done to enter the Physical Exam information ad File View EZA 2 0 0 85 2 HOA Nec 2 4 uii 8 EBE REFE m 5 C vials cc wer
33. vironmental followed by the allergen for example Shellfish NoteSwift will search for the allergen in Aprima and the cursor will jump to the Reaction box Dictate one or more reactions and then press the Next hotkey to enter the allergen into Aprima 3 25 2014 Smit File View amp OMERA EDA DEOR Ne HS Cn Ade amp e m x EB ES BE ES 0 a 5 CD vials cc ue Resus Ros re ox m se so Plan _ Assessment Forms Confdental CPP v Notes 8 s Record Date Delete uoneig Ej swawyomy ngs Allergies Complete 3 items I have reviewed the Food Allergy with patient Click or say Done when you are finished entering allergies To enter a comma delimited list of reactions dictate commas between them For example hives comma rash Note Swift Physical Exam Call up the Physical Exam form Exam This section has been designed to facilitate either a top down examination by entering each item explicitly or examination by exception We ll start with a top down example Aprima has systems categorized under parent systems which are what you see first However you can just dictate the system instead of first navigating through the parent system Say Cranial Nerves CN3 extraocular movements intact Left nystagmus on left gaze M File View 8 SE 2 26 ED 2 8 lt Nee ER Cn idR Ss x t Eos H a
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